Despite an overwhelming interest from anesthesiology residents in the United States to participate in global health, too often global health outreach in anesthesiology is misconstrued as being synonymous with “mission trips” to provide clinical care (J Clin Anesth 2012;24:38-43). This reflects an outdated and inadequately decolonized understanding of global health within our field, and we must shed the misperception that global health is something that is only done elsewhere to serve communities other than our own. COVID-19 has laid bare the fact that inequities and the structural violence that holds them in place are as relevant in wealthy countries as they are in less economically advanced parts of the world. The deep roots of these inequities, from systemic racism to capitalism, have a profound impact on the care anesthesiologists provide and on the perioperative outcomes of our patients (BMJ Glob Heal 2020;5:e003394).
Anesthesiologists have a role in many health care disparities. Examples include the fact that Black women in the U.S. are less likely than White women to receive neuraxial anesthesia for cesarean delivery, and American Indian and Alaskan Native veterans are more likely to die in the 30 days following surgery than their White brothers and sisters in arms (Anesth Analg 2016 Feb;122:472-9; J Am Coll Surg 2005;200:837-44). Global health and the inequities it seeks to address exist everywhere. The University of California, San Francisco (UCSF) Anesthesia Division of Global Health Equity (ADGHE), part of UCSF's multi-departmental Center for Health Equity in Surgery and Anesthesia (CHESA), has structured initiatives to address inequity at the local, regional, and international levels.
At the local level, UCSF's ADGHE has created a novel health equity curriculum for all anesthesia and surgery residents to allow them to conceptualize how inequity shapes health. Subjects include social determinants of health, health disparities between and within countries, health equity, structural racism, implicit bias, safety-net health systems, and community engagement. The curriculum comprises a combination of didactic lectures, small-group discussions, and case-based learning. Only through exposure to these topics can it be expected that future anesthesiologists understand that global health equity principles are relevant in all practice settings and that accounting for them directly impacts patient care and our ability to advocate for patients. An understanding of these principles is also required to meet current ACGME standards. The curriculum ensures that no UCSF anesthesia or surgery residents complete their training having not developed fundamental competencies in the above topics. This structured approach to global health equity education provides an opportunity to ensure clinicians have the necessary knowledge to take the lead on a crucial aspect of health care in the decades to come.
In addition to the curriculum, the ADGHE's local projects aim to increase access to quality perioperative care and address structural forces that impact care. Examples include the introduction of multilingual perioperative consent videos for Spanish- and Cantonese-speaking patients to improve the preoperative consent process and improve non-English speaking patients' perioperative experiences and a study that quantifies the impact of gentrification on minority access to safety-net hospital care in the Bay Area. These projects exemplify opportunities to address health disparities and inequities at the local level.
At the regional level, the ADGHE continues to walk together with the UCSF HEAL Initiative (healinitiative.org), the largest global health fellowship in the U.S., in their long-term partnership on Navajo Nation. Health disparities disproportionately impact Navajo Nation, the largest Native American reservation in the U.S. by land area (asamonitor.pub/36FSVyp). These health disparities and the inequities underpinning them drive the HEAL Initiative's commitment to work in solidarity with communities on Navajo Nation. The majority of HEAL's fellows spend half of their two-year fellowship working in Navajo Nation alongside federally and tribally employed providers, helping fill provider vacancy rates that consistently hover around 30% (asamonitor.pub/3g9aDgz). HEAL emphasizes solidarity and reciprocity by ensuring about half of each fellowship class is composed of health care providers from the Navajo community and international partner sites and offering an option for all fellows to complete funded graduate education during fellowship. UCSF's ADGHE provides career and research mentorship to HEAL fellows in surgery and anesthesia while also providing a resource to the broader HEAL community and their Navajo Nation colleagues on a wide variety of topics, including critical care and pain management.
In early 2020, Navajo Nation President Jonathan Nez asked for health care reinforcements when his community had the highest rate of COVID-19 infection per capita in the U.S. The HEAL Initiative's long-term partnership with Navajo Nation enabled them to recruit a cohort of UCSF providers, including members of UCSF's ADGHE, to respond to President Nez's request. The solidarity team joined a large network of HEAL fellows and alumni who had all been working on Navajo Nation preceding the pandemic. The team worked alongside local colleagues at the five largest hospitals serving Navajo patients, bearing witness to their resourcefulness in a system funded with 30 cents on the dollar of other federal health funding per capita and their resilience in the face of broken treaty obligations and a society that seemed to value their lives less (asamonitor.pub/3lBknl4). The short-term solidarity response was only a bandage on resource, personnel, and structural inequities that existed on Navajo Nation before COVID-19, and which will exist after. UCSF's ADGHE continues to support HEAL fellows' work on projects focused on improving access to epidural analgesia currently unavailable at some facilities, developing protocols to safely perform surgery during the pandemic, and developing UCSF anesthesia resident rotations on Navajo Nation.
At the international level, the COVID-19 pandemic has exposed how health care challenges in one country can quickly impact the entire world and has revealed the vulnerability and inequity present in most health care systems. Global health is being redefined, and with this process comes an opportunity for North-South collaboration to be undertaken in a more sustainable way to solve health care issues wherever they may exist.
UCSF's ADGHE and CHESA have been key partners to the anesthesia and surgery environments in Uganda. The approach has been to work closely with local colleagues in Uganda to set up a robust and dynamic collaboration to achieve long-term goals. The collaboration has over time focused on: 1) Educational infrastructure by providing training resources and simulation centers at Makerere University College of Health Sciences and at Busitema University Faculty of Health Sciences; 2) Workforce capacity-building through fellowships, sponsorships, and scholar positions for graduates transitioning into practice; and 3) Research mentorship of Ugandan-trained anesthesiologists. Further, there is a flourishing partnership with the Association of Anesthesiologists of Uganda to strengthen services through advocacy, generation of research, and practice models to inform the development of national surgical, obstetric, and anesthesia plans. These areas are catalysts for the growth of surgical services in Uganda and contrast from the common “short-term medical missions” and “data mongering” that have too often characterized surgery and global health. As part of the ongoing partnership, the anesthesia fraternity in Uganda has created opportunities for global health experiences for both faculty and trainees from UCSF, with many Ugandan faculty leading projects that contribute to their own career development.
Opportunities to enrich our practice and improve patient outcomes exist everywhere. From our own backyards to Navajo Nation to Uganda, it is clear that inequity dramatically impacts the practice of anesthesiology and is not contained by city limits, reservation boundaries, or national borders. Anesthesiology training programs and anesthesiology societies should champion a structured approach to health equity education to develop and empower globally conscious providers equipped with the tools to confront health equity challenges wherever they occur and prepare them to take a leading role in what will be a defining feature of 21st-century health care. Additionally, engaging with health disparities in multiple contexts strengthens our ability to recognize and combat disparities in our own communities. Anesthesiologist-led teams provide life-saving and life-altering care to our most vulnerable populations. We should use our privileged position to see and address injustices without looking away. These are all steps toward the goal of health equity for all.